| Abstract: |
Essential palmar hyperhidrosis is an embarrassing troublesome pathological condition that results in social,psychological and professional handicapping In the past various treatment modalities,including medical and surgical method have been introduced.However surgical T2-T3 sympathectomy remains the best choice of cure.In1910, Jacobaeus develop the technique of thoracic endoscopy. Open surgical sympathectomy carries the risk of complications e.g.Horner’s syndrome,postoperative pain,long convalescence,bad cosmetic results and high costs. Nowadays T.E.S is replacing open operations as the method of choice for upper extremity sympathectomy as a treatment of modality in palmar hyperhidrosis and the surgical treatment of choice in hyperhidrosis.At first ablation of the sympathetic chain was done by electrocautery endoscopically, but recently different methods of transthoracic endoscopic sympathectomy has been introduced using the Harmonic scalpel for sympatholysis, Endoclipper for clipping of the chain orLigasure for ligation of the chain. This work evaluates different methods of thoracic endoscopic T2- T3 sympathectomy as anew minimally invasive technique in primary palmar hyperhidrosis and T2-T3-T4 sympathectomy in peripheral vascular diseases e.g.Raynaud’s disease and Buerger’s disease and in causalgia and reflex sympathetic dystrophy by Harmonic scalpel,clipping , Ligasure and electrocautery. A total of 50 patients were selected for 100 sympathectomies in this study.Patients were chosen on the ground of social and economic problems resulting from palmar hyperhidrosis and they were seriously affected by palmar sweating during work and those with severe cyanosis of finger tips in case of Raynaud’s disease or ulcers and dystrophic changes in case of Buerger’s disease.Every patient were subjected to detailed clinical history and examination.Particular attention was paid to history of past or present tuberculosis,pleural adhesions or pulmonary pathology who were excluded.Preoperative chest X-ray was performed for every patient,and also complete investigation to exclude secondary hyperhidrosis and clinical, laboratory investigation to differentiate peripheral vascular diseases from atherosclerosis.Thoracoscopic sympathectomy were performed bilaterally at the same sitting with one lung anaesthesia,50by electrocautery,20by harmonic scalpel,20 by ligation and 10 by clipping Postoperative assessment include: 1.Immediately postoperative chest X-Ray.2.Study of the degree to which palmar sweating has been inhibited, Immediately postoperative and one year after operation by sweating test .3.The results of transthoracic endoscopic sympathectomy in the treatment of primary palmar hyperhidrosis and are discussed as regards: duration of the procedure, length of hospital stay, success rate, complications, postoperative pain and time for returning to normal life.Transthoracic endoscopic sympathectomy(T.E.S) is a minimally invasive procdure with several advantage over open surgery in the treatment of palmar and axillary hyperhidrosis and peripheral vascular diseases.It is simple, quick, easy and safe procedure for sympathetic denervation of the upper limb.It can be safely performed by any surgeon with laparoscopic training.It provide excellent visualization of the sympathetic chain, better in fact than open surgery and better protection of the stellate ganglion which lies above the operative field covered by the yellow of pad of fat. Therefore the risk of Horner’s syndrome is virtually absent. It has the advantage of simple access to T4,which is important in the control of axillary sweating.There is no advantage of one method(harmonic scalpel, ligasure, diathermy and clipping) over another in ablation of the sympathetic chain as regard the results and postoperative complications,but the harmonic scalpel is characterized by the least transmission of heat and thus the least method to cause postoperative pain,clipping is better in that there is a possibility to reverse operation for endoclip removal in case of compensatory sweating.We suggest that transthoracic endoscopic sympathectomy by monopolar diathermy is a cheap &feasible method and of proven benefit as regard the postoperative complications and results for the treatment of the palmar and axillary hyperhidrosis and peripheral vascular diseases.
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